54 - first heart sound - S1

Q- first heart sound is soft in all of the following conditions , except

a- short PR interval
b- ventricular septal defect
c- mitral regurgitation
d- calcified valve

the answer is a . short PR interval .

the first heart sound also called S1 is loud only in two conditions , one is the short PR interval and the other is the AORTIC STENOSIS .

the first heart sound is soft in the following conditions :

1- LONG PR INTERVAL

2- VENTRICULAR SEPTAL DEFECT

3- MITRAL REGURGITATION

4- CALCIFICATION IN MITRAL STENOSIS .

the first heart sound is normally produced due to the closure of the AV valves .

53 - pulsus paradoxus

Q- pulsus paradoxus is seen in all except ?

a- IPPV
b- cardiac tamponade
c- constrictive pericarditis
d- C O P D

the answer is a . intermittent positive pressure ventilation .

normally during inspiration there is decrease in the systolic blood pressure and arterial pulse volume , but in pulsus paradoxus this decrease is greatly accentuated .

the paradox here is that in conditions like cardiac tamponade , airway obstruction and constrictive pericarditis the decrease in systolic blood pressure is so much that the pulse cannot be felt but on auscultation we can hear the heart sounds . thats the paradox here .

the conditions in which pulsus paradoxus is seen are

CARDIAC TAMPONADE

CONSTRICTIVE PERICARDITIS

C . O . P. D /ACUTE SEVERE ASTHMA

SUPERIOR VENACAVAL OBSTRUCTION .

refer harrisons book of medicine - page 1255 - 15 th edition and page 1305 - 16 th edition .

----

PULSUS PARADOXUS CLINICALLY , ELECTRICAL ALTERANS ON ECG AND RVDC(right ventricular diastolic collapse) ON

ECHOCARDIOGRAPHY ARE CHARACTERISTIC FEATURES OF CARDIAC TAMPONADE .

Q- electric alterans is seen in ?

a- cardiac tamponade
b- restrictive cardiomyopathy
c- right ventricular infarct
d- constrictive pericarditis

answer is a .

52 - pulsus bisferiens

Q- pulsus bisferiens is best felt in ?

a- carotid arteries
b- brachial arteries
c- radial artery
d- femoral artery

the answer is c .

normally the central arteries like the carotid and the brachial give much information about the left ventricular function or aortic valve function ,but pulses like pulsus bisferiens and pulsus alterans are best felt in the peripheral arteries .

pulsus bisferiens is a pulse with 2 systolic peaks and it is seen in conditions like

AORTIC REGURGITATION

and

HYPERTROPHIC CARDIOMYOPATHY .

REFER HARRISONS BOOK OF MEDICINE - 15 th edition -PAGE 1255 AND 1305 - 16 th edition.

51 - food poisoning

Thirty-eight children consumed eatables procured from a single source at a picnic party. Twenty children developed abdominal cramps followed by vomiting and watery diarrhea 6-10 hours after the party. The most likely etiology for the outbreak is:

1. Rotavirus infection.
2. Entero-toxigenic E.Coli infection
3. Staphylococcol toxin.
4. Claustridium perfringens infection.



Answer

4. Claustridium perfringens infection.

Reference

Nelson is the book referred because we have 38 children going to the picnic
Nelson's Text book of Paediatrics. 15^th Edition Chapter 194 Anaerobic Infection

Discussion

Let us dissect this question

• 20 out of /38 (large number)
• Children – Look at Nelson (or Achar or Ghai ) Don’t go for Harrison or CMDT !!!)
• Single source /
• Picnic
• Abdominal cramps
• Vomiting
• Watery diarhhoea
• 6 - 10 hours

By the way in ADULTS ( not for this question, but as a general rule

C. perfringens food poisoning develops –

8 to 24 hrs after the consumption of contaminated food.

Fever and vomiting are uncommon - Harrison's,15th Pg-923

S. aureus food poisoning develops –

2 to 6 hrs after the consumption of contaminated food.

Crampy abdominal pains, vomiting & diarrhoea are the usual features - Harrison's,15th,Pg-893

So if you get these features in an adult, the time favours Clostridium and the Presence of Vomiting Staph !!!

But our question deals with CHILDREN and so we are relieved to have one answer

Feature	Staph	Cl.Perfinges	Our Question	Inference
Time of Onset	Harrison(as quotee above) Anathanarayanan’s Microbiology(Staph - within 6 hours) as well as CMDT say that staph occurs within 6 hours…… in fact CMDT 42nd Edition (2002) Table 30.3 and in the text 2 pages before it classify food poisoning based on Incubation period and in Staph that occurs because of preformed toxin Nelson :		6 - 10 hours	Strongly favours Cl.perfinge rules out Staph
Watery Diarhhoea	+ in CMDT	+++ in CMDT	Watery diarhhoea	Cl.Perfinges
Vomiting	Starts with vomiting	Nelson : Nausea 25 % Emesis 15 % CMDT : Vomiting may occur	Vomiting following cramps	??
abdominal cramps		Nelson : Cramps	Cramps	Cl.perfinges
Single source/ > 1 child			Fodd Poisoning	Can be both
Fever Uncommon		harrison	No fever	Cl.Perfinges
Children			We have to refer Nelson first and then Harrison	Cl.Perfinges

Now you see that only one point from Harrison favors Staph ……….. that is presence of vomiting in Adult….. but in Paediatric age group according to Nelson, nausea and vomiting are present !!!! that means the symptoms in the 38 CHILDREN were due to Cl.perfinges

Explanation

1. Rotaviruses cause disease in virtually all mammals and birds. The virus is a wheel-like, double-shelled icosahedron containing 11 segments of double-stranded RNA.
2. Entero-toxigenic E.Coli infection
3. Staphylococcol Food poisoning may be caused by ingestion of enterotoxins preformed by staphylococci contaminating foods. Two to 7 hr after ingestion of the toxin, sudden, severe vomiting begins. (Nelson's Text book of Paediatrics. 15^th Edition Chapter 174.1)
4. Claustridium perfringens infection is the correct answer

Comments

CLOSTRIDIUM PERFRINGENS FOOD POISONING.

• Enterotoxin-producing C. perfringens type A causes a mild and common form of food poisoning.
• The enterotoxin,
  • a structural component of the spore coat,
  • is a protein with a molecular weight of 35,000 daltons,
  • is resistant to trypsin digestion,
  • binds to a brush border membrane receptor,
  • disrupts cell integrity, and
  • causes cell death.
• Food poisoning follows ingestion of
  • contaminated cooked meats,
  • poultry,
  • stew,
  • meat pies, and
  • gravies that have undergone long periods of slow cooling and ambient temperature storage, which facilitate spore survival.
  • Such food usually contains at least 10⁸ enterotoxin-producing Clostridium organisms, which during intestinal passage proliferate and produce toxin.
• Clinical manifestations include
  • diarrhea (90%),
  • abdominal cramps (80%),
  • nausea (25%),
  • emesis (15%), and
  • fever (25%) with
  • spontaneous resolution in 6–24 hr.
• The incubation period is
  • brief (7–15 hr), and
• History may reveal a
  • common exposure with others who are ill.
• The diagnosis is confirmed by
  • detection of 10⁵ or more C. perfringens in the food source,
  • at least 10⁶ organisms/g stool within 48 hr of onset, and
  • detection of enterotoxin with ELISA or other immunoassay.
• The differential diagnosis includes food poisoning from
  • preformed toxins (S. aureus, B. cereus, C. botulinum),
  • in vivo toxin generation (B. cereus, toxigenic E. coli),
  • invasive enteric pathogens (C. jejuni, Salmonella, Shigella, E. coli, Yersinia),
  • heavy metals (copper, tin, zinc),
  • scombroid (histamine), and
  • mushrooms.
• Treatment comprises
  • supportive care and
  • fluid and electrolyte replacement for gastrointestinal losses caused by this self-limited enterotoxemia.

Clinical Syndromes.
Several clinical syndromes follow the ingestion of contaminated food or water, (Nelson's Text book of Paediatrics. 15^th Edition Chapter 171 )

• Nausea and vomiting within 6 hr
  • Toxins that produce direct gastric irritation,

• Such as heavy metals, or with
• Preformed toxins of
  • B. cereus (B. cereus also produces an enterotoxin )or

• S. aureus;;
• Paresthesia within 6 hr; Paresthesias after a brief incubation period are suggestive of
  • scombroid (histamine fish poisoning),
  • paralytic or neurotoxic shellfish poisoning,
  • Chinese restaurant syndrome (monosodium glutamate poisoning),
  • niacin poisoning, or
  • ciguatera fish poisoning
• Neurologic and gastrointestinal symptoms within 2 hr;
  • ingestion of toxic mushrooms
    • parasympathetic hyperactivity,
    • confusion,
    • visual disturbances,
    • and hallucinations to
    • hepatic or
    • hepatorenal failure, which occurs after a 6-24 hr incubation period.
• Abdominal cramps and watery diarrhea within 16–48 hr;
  • 8–16 hr incubation period
    • enterotoxin-producing Clostridium perfringens and
    • B. cereus.
• Fever, abdominal cramps, and diarrhea within 16–72 hr;
  • Salmonella,
  • Shigella,
  • C. jejuni,
  • Y. enterocolitica, and
  • enteroinvasive E. coli are associated with diarrhea, which may contain fecal leukocytes, abdominal cramps, and fever, although these organisms can cause watery diarrhea without fever.
• Abdominal cramps, bloody diarrhea without fever within 72–120 hr;
  • enterohemorrhagic E. coli, such as E. coli 0157:H7.
• Hemolytic uremic syndrome
  • enterohemorrhagic E. coli.
• Neurologic signs and symptoms within 6–24 hr; and nausea, vomiting, and paralysis within 18–48 hr
  • blurred vision,
  • dry mouth,
  • dysarthria,
  • diplopia, or
  • descending paralysis

should suggest C. botulinum as the cause

49 - medicine mcqs - 64 to 74

64 - In the treatment of chronic hepatitis B virus:
1. Corticosteroids are always beneficial
2. 40% of patients can be expected to respond to interferon
3. Combined treatment with acyclovir and interferon is more effective than interferon alone
4. Interferon can be associated with a rise in transaminases towards the end of therapy
2 and 4 are the right answers .
--------------------------------------------------------------------------------------------------------------------------------
65 - Which of the following statements is / are true of streptococcus pyogenes infections:
1. They account for less than 5% of upper respiratory infections in children under the age of 2 years
2. Rheumatic chorea is a recognised sequela
3. It is a cause of erysipelas
4. The treatment of choice is ampicillin
1 , 2 , 3 are the right answers .
--------------------------------------------------------------------------------------------------------------------
66 - The following may occur in uncomplicated haemolytic jaundice:
1. Bilirubinuria
2. High conjugated serum bilirubin
3. High serum alkaline phosphatase
4. Reticulocytosis
only 4 is correct .
--------------------------------------------------------------------------------------------------------------------
67 - Nephrotoxicity is described with the following drugs:
1. Gentamicin
2. Acetazolamide
3. Ampicillin
4. Rifampicin
all are correct .
-----------------------------------------------------------------------------------------------------------------------
68 - With reference to transplant immunology:
1. Hyperacute rejection is mediated by T-cells
2. Chronic rejection is immunoglobulin mediated
3. Early acute rejection is mediated by B-lymphocytes
4. Steroids are effective in reversing acute rejection of a donor organ
2 and 4 are correct .
-----------------------------------------------------------------------------------------------------------------
69 - The following are recognised associations:
1. Ulcerative colitis and HLA B8
2. Primary sclerosing cholangitis and HLA B8
3. Haemochromatosis and HLA A3
4. Primary biliary cirrhosis and HLA DR3
2 and 4 are right .
-------------------------------------------------------------------------------------------------------------------
70 - Pleural calcification is a recognised result of:
1. Tuberculosis
2. Chronic empyema
3. Asbestosis
4. Bagassosis
1 , 2 , 3 are right .
--------------------------------------------------------------------------------------------------------------------------
71 - The early manifestations of chronic inorganic lead poisoning include:
1. Absent knee reflexes
2, Punctate basophilia
3. Constipation
4. Abdominal colic
2 and 4 are right .
----------------------------------------------------------------------
72 - Temporal lobe epilepsy is particularly associated with:
1. Dreamy states
2. Euphoria
3. An olfactory aura
4. Repetitive conjugate movements of the eyes
1 and 3 are right .
-------------------------------------------------------------------------------------
73 - Myocarditis:
A may present with a functional systolic murmur
B usually causes hypertension
C causes nonspecific ST changes on ECG
D is often caused by Coxsackie virus
E is worsened by hypoxia and exercise
1. A=T, B=F, C=T, D=T, E=T.
Myocarditis may cause a systolic murmur on auscultation because of cardiac dilatation. The blood pressure in myocarditis is often normal, but if myocardial damage is severe there may be severe hypotension.
---------------------------------------------------------------------------
74 - Cardiomyopathy:
A is primarily characterised by right ventricular dilatation
B is associated with thyrotoxicosis
C is usually associated with valve calcification
D secondary to alcohol has a good prognosis
E may be a cause of the sudden death syndrome
2. A=F, B=T, C=F, D=F, E=T.
Cardiomyopathy is recognised by left rather than right ventricular dilatation and systolic dysfunction in the absence of coronary artery, valvular, congenital or peripheral disease. Thus according to this definition, cardiomyopathy would not be associated with valve calcification. Cardiomyopathy is associated with thyrotoxicosis and acromegaly. Alcoholic cardiomyopathy has a poor prognosis 40-50% are dead within 3 to 6 years.
---------------------------------------------------------

48 - medicine mcqs - 53 to 63

53 - A 27 year old, otherwise fit man gives a history suggestive of recurrent tachyarrhythmias. During a previous anaesthetic he apparently arrested and required DC cardioversion. He now presents for an arthroscopy. His ECG is shown below.
The most likely diagnosis is:
A. Lown Ganong Levine syndrome.
B. Prolonged QT syndrome.
C. Wolff Parkinson White syndrome.
D. Sick Sinus syndrome.
E. Atrio-Ventricular (AV) nodal re-entrant tachycardia.

ANSWER IS C - WPW syndrome
--------------------------------------------------------------------------------------------
54 - Which of the following is a risk factor for increased susceptibility to drug-induced 'Torsades de pointes'?
A. Male Gender.
B. Hypokalaemia.
C. Hypermagnesaemia.
D. Sinus tachycardia.
E. None of the above.
THE ANSWER IS B . HYPOKALEMIA
---------------------------------------------------------------------------------------------------
55 - A fifty year old man suffers an acute myocardial infarction (MI). In which of the following conditions is temporary transvenous pacing most clearly indicated?
A. First-degree heart block.
B. Mobitz type I second-degree AV block with normal haemodynamics.
C. Mobitz type II second-degree AV block.
D. Accelerated idioventricular rhythm.
E. Bundle branch block known to exist before the acute MI.
ANSWER IS C .
-----------------------------------------------------------------------------------------------------------------
56 - With regard to the Dandy-Walker syndrome:
1. The cerebellar vermis is hypoplastic.
2. Obstructive hydrocephalus is the commonest mode of presentation.
3. Presentation usually occurs within the 1st two years of life.
4. A cyst is always present in the posterior fossa
all are correct .
-------------------------------------------------------------------------------------------------------
57 - In transfusion practice:
1. Fever is usually due to anti-leucocyte antibodies
2. Desmopressin (DDAVP) will raise levels of factor VIII in patients with mild haemophilia A
3. Haemolytic reactions may be delayed for up to 1 week
4. Severe anaphylaxis may be seen in IgA deficient individuals
all are true .
---------------------------------------------------------------------------------------------------------------------------------------------
58 - Recognised causes of macrocytosis in the peripheral blood with normoblastic erythropoiesis in the bone marrow include:
1. Hypothyroidism
2. Chronic alcohol abuse
3. Cryptogenic cirrhosis
4. The administration of phenytoin
1 , 2 , 3 are correct .
---------------------------------------------------------------------------------------------------------------------------------------
59 - Which are true of Hepatitis E virus?
1, It is a 34nm single stranded RNA virus.
2. It is more common in IV drug abusers
3. Can produce epidemic waterborne infections
4. Will cause 10% of patients to develop chronic hepatitis
1 and 3 are correct .
----------------------------------------------------------------------------------------------------------------
60 - Which of the following are correctly paired?
1. Conn's syndrome and metabolic alkalosis
2. Uretero-colic anastomosis and hyperchloraemic acidosis
3. Shock and metabolic acidosis
4. Pancreatic fistula and metabolic acidosis
all are correctly paired .
---------------------------------------------------------------------------------------------------------------
61 - The following are recognised causes of pulmonary fibrosis:
1. External raditaion for carcinoma of the breast
2. Bleomycin
3. Sarcoidosis
4. Myelofibrosis
1 , 2 , 3 are correct .
----------------------------------------------------------------------------------------------------------------
62 - Recognised causes of finger clubbing include:
1. Carcinoid tumour
2. Bronchial carcinoma
3. Iron deficiency anaemia
4. Coeliac disease
2 and 4 are the answers .
--------------------------------------------------------------------------------------------------------------------
63 - Dupuytren's contracture has a recognised association with:
1. Diabetes Mellitus
2. Peyronie's disease
3. Epilepsy
4. Alcoholic liver cirrhosis
all are correct .
------------------------------------------------------------------------------------------------------------------

39 - stroke mcqs

Question 1 : Swallowing disorders associated with cortical stroke:

1. Rarely result in aspiration pneumonia
2. Are usually more severe than in brain stem stroke
3. Are usually severe and permanent
4. Respond to thermal stimulation therapy------------------------------------------------ *
5. Are always clinically apparent with coughing and choking

Question 2 : A lacunar stroke will most likely cause:

1. visual field deficits
2. hemiparesis----------------------------- *
3. aphasia
4. agraphia
5. neglect

Question 3 : In the retraining of mobility following stroke, the first step is:

1. fitting with an AFO
2. achieving safe transfers
3. achieving standing balance
4. achieving sitting balance
5. achieving independent bed/mat mobility * * Right

Question 4 : A 69 year-old woman with right hemispheric stroke and resultant swallowing difficulties has a dense left hemiplegia, and left neglect but follows multiple step commands without hesitation. The dysphagia is most likely results from:

1. Decreased level of alertness
2. Impaired oral movement or sensation * * Right
3. Paralyzed vocal folds
4. Gastroesphageal reflux
5. Oral muscle spasticity

Question 5 : The most common type of stroke is:

1. Lacunar
2. Embolic
3. Thrombotic------------------------- *
4. Intracerebral hemorrhage
5. Subarachnoid hemorrhage

Question 6 : A term for the language deficit accompanying cerebral stroke is:

1. agraphia
2. anosognosia
3. dysphagia
4. aphasia------------------------------------- *

Question 7 : The percentage of patents with urinary incontinence one year after stroke is approximately:

1. 20% or less * * Right
2. 25-30%
3. 40-50%
4. 60-70%
5. More than 70%

Question 8 : Urinary incontinence one week after stroke is best handled by:

1. Indwelling urinary catheter
2. Condom catheterization
3. Intermittent catheterization
4. Timed voids * * Right

Question 9 : The inability to carry out a motor task on command given adequate strength, sensation, coordination and comprehension is called:

1. Aphasia
2. Apraxia * * Right
3. Alexia
4. Aprosodia
5. Abulia

Question 10 : A 64 year-old right handed male presents with right upper limb plegia, right lower limb paresis, a hemisensory deficit, a decreased ability to comprehend verbal or written commands and poor language output. His lesion is most likely in the:

1. Anterior cerebral artery distribution
2. Basal ganglia
3. Middle cerebral artery distribution * * Right
4. Posterior cerebral artery distribution
5. Brain stem

35 - CVS pathology mcqs - 36 to 40

Question 36
A 51-year-old man has the sudden onset of substernal chest pain which radiates to his left arm and neck. He becomes light-headed and diaphoretic over the next 3 hours. He goes to the emergency room. On examination he is afebrile but has a heart rate of 96/minute with an irregular rhythm. Laboratory studies show a serum CK-MB of 15% with total CK of 524 mg/dL. Which of the following features would be most prominent by histopathologic examination of his myocardium at this point in time?
A Macrophage infiltration
B Contraction band necrosis
C Neutrophilic infiltration
D Capillary proliferation
E Collagen deposition
----------------------------------------------------------------------

(B) CORRECT. This is an initial change as the myocardial fibers begin to die.
(A) Incorrect. Macrophages begin to appear at the end of the first week with an MI.
(C) Incorrect. Neutrophils begin to infiltrate the myocardium after the first day of an MI.
(D) Incorrect. Granulation tissue begins to form as the MI heals.
(E) Incorrect. Collagen is deposited in the healing phase of an MI.
---------------------------------------------------------------------

Question 37
A 58-year-old man has had an enlarging abdomen for 5 months. He has experienced no abdominal or chest pain. On physical examination he has a non-tender abdomen with no masses palpable, but there is a fluid wave. An abdominal CT scan shows a large abdominal fluid collection with a small cirrhotic liver. A chest radiograph shows a globally enlarged heart. He has vital signs showing T 37.1 C, P 78/minute, RR 16/minute, and BP 115/75 mm Hg. Which of the following cardiovascular conditions is he most likely to have?
A Severe occlusive coronary atherosclerosis
B Lymphocytic myocarditis
C Myocardial amyloid deposition
D Nonbacterial thrombotic endocarditis
E Dilated cardiomyopathy
--------------------------------------------------------------------

(E) CORRECT. The cardiomyopathy of chronic alcohol abuse has a dilated or congestive appearance.
(A) Incorrect. In general, persons with chronic alcoholism have less atherosclerosis.
(B) Incorrect. There is no increased risk for myocarditis in alcoholism.
(C) Incorrect. Alcoholism is not a risk factor for amyloidosis of any kind.
(D) Incorrect. Nonbacterial thrombotic endocarditis (NBTE) is a form of non-infective endocarditis that can occur in severely debilitated patients, though hypercoagulability that contributes to this process is not favored by chronic liver disease.
-------------------------------------------------------------------------

Question 38
A 77-year-old man has developed increasing dyspnea for the past 3 years. On physical examination he has a diastolic murmur. A chest radiograph shows an enlarged heart and prominent aorta. He dies from complications of pneumonia. At autopsy, the thoracic aorta is aneurysmally dilated. A microscopic section of the aorta shows chronic inflammation and luminal narrowing of vasa vasora. There is disruption of the aortic medial elastic fibers. Which of the following conditions is most likely to cause these findings?
A Hypercholesterolemia
B Marfan syndrome
C Polyarteritis nodosa
D Takayasu arteritis
E Tertiary syphilis
F Wegener granulomatosis
---------------------------------------------------------------------------

(E) CORRECT. T. pallidum is the organism that causes syphilis. The endaortitis of the vasa vasora affects the media of the aorta, leading to buckling of the intimal surface in a 'tree bark' pattern, and aneurysmal dilation, including the aortic root, causing aortic regurgitation. This happens decades following initial infection.
(A) Incorrect. Hypercholesterolemia is a risk factor for atheroscclerosis, which most often affects the abdominal aorta, leading to aneurysm formation. Mural thrombus is prone to develop when blood flow patterns are abnormal, as in an aneurysm.
(B) Incorrect. Marfan syndrome leads to cystic medial necrosis, not endaortitis, and appears earlier in life.
(C) Incorrect. Classic polyarteritis nodosa most often involves small to medium-sized muscular arteries, including renal and mesenteric arteries, and sometimes veins, with necrosis and microaneurysm formation.
(D) Incorrect. Takayasu arteritis can involve the aorta, particularly the arch, and branches such as coronary and renal arteries with granulomatous inflammation, aneurysm formation, and dissection. It appears at a much earlier age.
(F) Incorrect. Wegener granulomatosis involves small arteries, veins, and capillaries with mixed inflammation, necrotizing and non-necrotizing granulomatous inflammation withgeographic necrosis surrounded by palisading epithelioid macrophages and giant cells.
----------------------------------------------------------------------------

Question 39
A 23-year-old primigravida gives birth following an uncomplicated pregnancy to a 2870 gm girl infant. The baby initially does well, but then approximately 12 hours following delivery develops respiratory difficulty. On examination the infant has a poor color, weak pulses, and oxygen saturation of only 90%. Which of the following cardiac findings is this infant most likely to have?
A Muscular ventricular septal defect
B Hypoplastic left heart
C Complete transposition with no shunt
D Secundum type atrial septal defect
E Congenital infection with Group B streptococcus
--------------------------------------------------------------------

(B) CORRECT. The poor outcome so soon after birth suggests a severe defect, and lack of sufficient left heart to provide appropriate cardiac output can explain these findings. There can be varying degrees of hypoplasia which determine how long the child survives.
(A) Incorrect. Even a large VSD should not be fatal in such a short time.
(C) Incorrect. If a transposition is present with no shunt, then any survival is not possible, as the systemic and pulmonary circulations would be completely separate.
(D) Incorrect. ASD's create a shunt, but the lack of a significant pressure difference between left and right atrium means that cardiac function is not severely affected.
(E) Incorrect. Group B strep infections may produce fetal or neonatal loss, but do not typically produce congenital heart defects. However, congenital rubella in the first trimester can lead to cardiac defects.
---------------------------------------------------------------------------

Question 40
A 66-year-old man has had increasing malaise for the past year. On physical examination auscultation of the chest reveals a friction rub. Laboratory studies show a serum urea nitrogen of 100 mg/dl and creatinine of 9.8 mg/dl. Which of the following forms of pericarditis is he most likely to have?
A Fibrinous
B Hemorrhagic
C Purulent
D Serous
E Constrictive
---------------------------------------------------------------------

(A) CORRECT. The uremia leads to exudation of fibrin onto the epicardial and pericardial surfaces.
(B) Incorrect. This is more typical of tuberculosis or metastatic tumor.
(C) Incorrect. This is not common but can occur with spread of infection from lung or mediastinum.
(D) Incorrect. This is more typical for collagen vascular diseases.
(E) Incorrect. This is a late complication of tuberculous pericarditis. It may also follow cardiac surgery or radiation to the chest.
--------------------------------------------------------------------------

32 - CVS pathology mcqs - 21 to 25

Question 21
While playing cards, a 63-year-old woman has the sudden onset of "knife-like" pain in the chest radiating to the back. She has been previously healthy except for a history of poorly controlled hypertension. Paramedics are called, and she is transported to the hospital. On admission, she has a heart rate of 90/minute, respirations 20/minute, temperature 36.8 C, and blood pressure 150/100 mm Hg. No murmurs, rubs, or gallops are audible. A chest radiograph reveals a widened mediastinum. Laboratory findings include a total serum creatine kinase of 55 U/L, creatinine 0.9 mg/dL, and glucose 123 mg/dL. Which of the following is the most likely diagnosis?
A Fibrinous pericarditis
B Aortic intimal tear
C Infective endocarditis
D Dilated cardiomyopathy
E Myocardial infarction
------------------------------------------------------------

(B) CORRECT. This is a classic history for an aortic dissection. A tear in the aortic intima is followed by dissection of blood outward, often to the thoracic cavity, with fatal hemothorax. The risk factors in most adults include atherosclerosis and hypertension. In Marfan syndrome, the risk for aortic dilation and dissection results from cystic medial necrosis, but this occurs at a much younger age.
(A) Incorrect. A pericarditis can produce pain, but not typically knife-like and not suddenly.
(C) Incorrect. Infective endocarditis is not typically associated with chest pain, unless a septic embolus occludes a coronary artery.
(D) Incorrect. Cardiomyopathies are not typically associated with chest pain.
(E) Incorrect. The pain of a myocardial infarction more typically is substernal and crushing, with radiation to the arm, but an MI needs to be ruled out.
-----------------------------------------------------------

Question 22
A 20-year-old primigravida delivers a term baby girl following an uncomplicated pregnancy. No anomalies are noted at the time of birth. Five weeks later, the mother brings the baby to the clinic because she has difficulty breathing and occasionally turns pale. On physical examination a pansystolic murmur is audible. Which of the following congenital cardiac anomalies is most likely to be present in this infant?
A Hypertrophic subaortic stenosis
B Hypoplastic left heart syndrome
C Coarctation of the aorta
D Ventricular septal defect
E Bicuspid aortic valve
-------------------------------------------------

(D) CORRECT. The most common cardiac defect is a VSD. The baby may first become symptomatic when the pulmonary arteries dilate after the first month of life and the shunting from left-to-right increases.
(A) Incorrect. IHSS is a rare cause for a hypertrophic cardiomyopathy, and it occurs in adults.
(B) Incorrect. This condition is manifested at birth. If the hypoplasia is not severe, the baby may survive.
(C) Incorrect. The preductal form seen in neonates is severe and usually accompanied by a patent ductus arteriosus.
(E) Incorrect. Although a bicuspid valve is present at birth, it functions fairly well. It calcifies and malfunctions in later adult life.
----------------------------------------------------

Question 23
A 65-year-old man has had congestive heart failure with increasing pulmonary congestion and edema for the past year. He had been previously healthy all his life with no major illnesses. On physical examination his blood pressure is 125/85 mm Hg and he is afebrile. A chest radiograph shows cardiomegaly with a prominent left heart border and pulmonary edema. Laboratory studies show a serum glucose of 95 mg/dL and total serum cholesterol of 175 mg/dL. His serum creatine kinase is not elevated. Which of the following underlying diseases is he most likely to have?
A Alcoholic cardiomyopathy
B Calcified bicuspid aortic valve
C Tricuspid valve endocarditis
D Aortic dissection
E Amyloidosis
------------------------------------------------

(B) CORRECT. Although bicuspid aortic valves are present from birth, they do not manifest with significant calcification and stenosis until later adult life. The lack of peripheral edema points to a left-sided cause for congestive failure.
(A) Incorrect. Both the right and the left heart are typically involved with a cardiomyopathy, and right-sided failure would lead to peripheral edema.
(C) Incorrect. Right-sided failure from tricuspid involvement with endocarditis would lead to peripheral edema.
(D) Incorrect. This most often results in abrupt onset of shock and/or chest pain.
(E) Incorrect. Amyloidosis produces a restrictive type of cardiomyopathy that typically involves both right and left heart.
-----------------------------------------------------

Question 24
A 35-year-old man was found down and was delirious and talking incoherently. On examination in the emergency department his temperature is 39.3 C, pulse 110/minute, and blood pressure 70/palpable. He has a heart murmur, palpable spleen tip, and splinter hemorrhages of fingernails. Which of the following laboratory findings is most likely to be present in this man?
A Positive urine screen for opiates
B Elevated anti-streptolysin O (ASO)
C Increased urinary free catecholamines
D Elevated Coxsackie B viral titer
E Rising creatine kinase (CK) in serum
------------------------------------

(A) CORRECT. This history points to an infective endocarditis. A common risk factor for infective endocarditis is intravenous drug use.
(B) Incorrect. He does not have rheumatic disease.
(C) Incorrect. He does not have a pheochromocytoma.
(D) Incorrect. He does not have a viral myocarditis.
(E) Incorrect. He does not have an acute myocardial infarction. The valvular disease does not necessarily involve the adjacent myocardium.
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Question 25
A 69-year-old woman with a 7 kg weight loss over the past 6 months now has developed painless jaundice over the past 2 weeks. On physical examination she is afebrile. An abdominal CT scan shows a large mass involving the head of the pancreas, along with widespread nodules in the liver. Nodules are seen in both lungs by chest radiograph. Which of the following cardiac lesions is she most likely to develop?
A Dilated cardiomyopathy
B Non-bacterial thrombotic endocarditis
C Acute fibrinous pericarditis
D Endocardial fibrosis
E Acute myocardial infarction
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(B) CORRECT. Such cancers can be associated with a hypercoagulable state (Trousseau's syndrome) with formation of marantic cardiac valvular vegetations.
(A) Incorrect. This is often idiopathic.
(C) Incorrect. Fibrinous pericarditis is most often seen with renal failure and uremia. It can also occur with myocardial infarction and with acute rheumatic fever.
(D) Incorrect. This is an uncommon idiopathic process in children. The left ventricle is involved more than the right by deposition of a thick collagen layer that interferes with contractility.
(E) Incorrect. Patients with advanced cancer often have a reversal of atherosclerotic lesions.
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31 - CVS pathology mcqs - 16 to 20

Question 16
A 21-year-old man has had increasing malaise over the past three weeks. On physical examination his vital signs show T 39.2 C, P 105/minute, RR 29/minute, and BP 80/40 mm Hg. The physician auscultates a loud systolic cardiac murmur. His lungs on auscultation have bibasilar crackles. Needle tracks are seen in his left antecubital fossa. He has splinter hemorrhages noted on fingernails, as well as painful erythematous nodules on palmar surfaces. A tender spleen tip is palpable. A chest radiograph shows pronounced pulmonary edema. Which of the following laboratory test findings is most likely to be present in this patient's peripheral blood?
A Creatine kinase-MB of 8% with a total CK 389 U/L
B Positive blood culture for Pseudomonas aeruginosa
C Total serum cholesterol of 374 mg/dL
D Blood urea nitrogen of 118 mg/dL
E Antinuclear antibody titer of 1:512
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(B) CORRECT. The history points to infectious endocarditis and acute congestive heart failure. Staphylococcus aureus and Pseudomonas aeruginosa are the most likely organisms to be found with a history of injection drug use.
(A) Incorrect. The CK-MB is typically elevated with ischemic heart disease, which would be unusual at his age.
(C) Incorrect. A cholesterol in this range could be seen with heterozygous familial hypercholesterolemia, which would be unlikely to manifest with ischemic heart disease at this age.
(D) Incorrect. His heart failure, if severe, could reduce cardiac output and lead to pre-renal azotemia if he survives.
(E) Incorrect. An autoimmune disease such as systemic lupus erythematosus can lead to non-infective endocarditis (Libman-Sacks endocarditis) in which there are small, non-destructive vegetations and no emboli.
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Question 17
A 2-year-old child has had failure to thrive for a year, becoming increasingly listless. On examination she is found to have a soft, rumbling systolic ejection murmur. An echocardiogram reveals a large membranous ventricular septal defect. Which of the following complications is she most likely to experience as an adult 2 decades later if this lesion remains untreated?
A Rib notching
B Mitral valve prolapse
C Pulmonary hypertension
D Myocardial infarction
E Cardiac tamponade
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(C) CORRECT. The left-to-right shunt eventually leads to pulmonary hypertension and reversal of the shunt (Eisenmenger complex).
(A) Incorrect. Rib notching is a rare finding that can be seen with post-ductal coarctation of the aorta.
(B) Incorrect. There is upward ballooning of a mitral leaflet with prolapse, due to attenuated chordae tendineae. (Note: a VSD sometimes becomes closed when a tricuspid leaflet adheres to the opening).
(D) Incorrect. Congenital heart disease is, in general, not a risk for ischemic heart disease.
(E) Incorrect. The defect is between the ventricular chambers and not connected to the pericardial sac.
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Question 18
A 42-year-old woman has noted increasing dyspnea for the past 6 years. On examination rales are auscultated in both lungs. She is afebrile. A chest radiograph shows an enlarged cardiac silhouette and bilateral pulmonary edema. Past history reveals that, as a child she suffered recurrent bouts of pharyngitis with group A beta hemolytic streptococcal infections. Which of the following cardiac valves are most likely to be abnormal in this woman?
A Aortic and tricuspid
B Mitral and pulmonic
C Aortic and pulmonic
D Tricuspid and pulmonic
E Mitral and aortic
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(E) CORRECT. She has chronic rheumatic valvulitis with scarring associated with rheumatic heart disease. If the tricuspid valve is involved, then the mitral and aortic are probably involved as well. The most common single valve involved is the mitral.
(A) Incorrect. The tricuspid valve is not often affected. When it is, the mitral and aortic valves are also affected, too.
(B) Incorrect. The mitral valve is the most common valve to be involved. The pulmonic valve is almost never involved.
(C) Incorrect. The aortic valve is the second most common valve to be involved. The pulmonic valve is almost never involved.
(D) Incorrect. The left side of the heart is involved far more commonly than the right with rheumatic heart disease.
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Question 19
A 25-year-old previously healthy woman has had worsening fatigue with dyspnea, palpitations, and fever over the past week. On physical examination her vital signs show T 38.9 C, P 103/minute, RR 30/minute, and BP 95/65 mm Hg. Her heart rate is slightly irregular. An ECG shows diffuse ST-T segment changes. A chest x-ray shows mild cardiomegaly. An echocardiogram shows slight mitral and tricuspid regurgitation but no valvular vegetations. Laboratory studies show a troponin I of 12 ng/mL. She recovers over the next two weeks with no apparent sequelae. Which of the following laboratory test findings best explains the underlying etiology for these events?
A Anti-streptolysin O titer of 1:512
B Total serum cholesterol of 537 mg/dL
C Coxsackie B serologic titer of 1:160
D Blood culture positive for Streptococcus, viridans group
E ANCA titer of 1:80
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(C) CORRECT. She has findings that suggest myocarditis, which can have features of cardiomyopathy. One of the most likely organisms is Coxsackie B virus.
(A) Incorrect. An elevation of the ASO titer suggests a recent streptococcal infection that might be associated with rheumatic fever. The infection, typically a pharyngitis, is gone by the time the ASO titer is elevated and the cardiac lesions, including myocarditis, are present.
(B) Incorrect. This level of cholesterol could be associated with familial hypercholesterolemia and risk for ischemic heart disease, even at a young age. This does not explain the fever.
(D) Incorrect. Viridans group of streptococcus is best known as a causative organism for subacute endocarditis, and valvular vegetations are present with forms of infective endocarditis.
(E) Incorrect. An antineutrophil cytoplasmic autoantibody can be detected with vasculitis, typically polyarteritis nodosa or Wegener granulomatosis.
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Question 20
A 44-year-old man has had no major medical problems throughout his life, except for arthritis pain involving all extremities for the past 5 years. He has had worsening orthopnea and pedal edema in the past 6 months. There is no chest pain. On examination he is afebrile. A chest radiograph shows cardiomegaly with both enlarged left and right heart borders, along with pulmonary edema. Laboratory studies show serum sodium 139 mmol/L, potassium 4.3 mmol/L, chloride 99 mmol/L, CO2 25 mmol/L, urea nitrogen 18 mg/dL, creatinine 1.3 mg/dL, and glucose 167 mg/dL. Which of the following additional laboratory test findings is he most likely to have?
A Spherocytes on his peripheral blood smear
B Hemoglobin of 10.7 g/dL with MCV of 72 fL
C Erythrocyte sedimentation rate of 79 mm/Hr
D Anti-centromere antibody titer of 1:320
E Serum ferritin of 8700 ng/mL
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(E) CORRECT. He has findings of a cardiomyopathy with right and left heart failure. Hereditary hemochromatosis can produce iron deposition in visceral organs, including the heart. The serum ferritin is a good indicator of body iron stores. Hemochromatosis affects the pancreas as well, leading to diabetes mellitus. Deposition of iron in joints leads to arthritis. The onset of disease is typically in the 40's in males and 60's in females.
(A) Incorrect. Spherocytosis can lead to a mild hemolytic anemia that stresses the heart somewhat to produce mild hypertrophy.
(B) Incorrect. An iron deficiency anemia in an adult could chronically lead to increased cardiac output. If severe enough, there could be a high-output cardiac failure. The heart will tend to enlarge somewhat. This does not explain his arthritis or hyperglycemia, though.
(C) Incorrect. An increased sed rate is a non-specific indicator of inflammation somewhere in the body.
(D) Incorrect. Anti-centromere antibody can be detected with sclerodema, which can produce cardiac findings resembling a cardiomyopathy, but hyperglycemia and joint problems are not part of scleroderma.
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30 - CVS pathology mcqs - 11 to 15

Question 11
A 27-year-old G2 P1 woman has a screening ultrasound performed at 18 weeks gestation. The fetus is appropriate in size for 18 weeks. The fetal kidneys, liver, head, and extremities appear normal. However, the fetus has a heart with a membranous ventricular septal defect, overriding aorta, and marked pulmonic atresia. If the baby were to be liveborn, which of the following characteristics on physical examination would most likely result from these cardiac defects?
A Systemic hypertension
B Weak lower extremity pulses
C Clubbing of digits
D Telangiectasias
E Cyanosis
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(E) CORRECT. The features are those of tetralogy of Fallot, which producces a right-to left shunt with cyanosis from mixing of right heart blood with left heart blood.
(A) Incorrect. The cardiac output tends to be reduced with tetralogy of Fallot. Systemic hypertension is not typically a feature of most congenital heart diseases.
(B) Incorrect. Weaker pulses in the lower extremities, compared to upper extremities, suggest coarctation of the aorta, not tetralogy of Fallot.
(C) Incorrect. Finger clubbing is more typically seen with chronic pulmonary diseases.
(D) Incorrect. Telangiectasias are small vascular prominences that are not generally associated with congenital heart diseases.
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Question 12
A 50-year-old man has the sudden onset of substernal chest pain one afternoon. The pain persists for the next three hours. He then becomes short of breath and diaphoretic. He goes to the emergency department that evening. On physical examination his vital signs include T 37 C, P 95/minute, RR 25/minute, and BP 130/90 mm Hg. A chest radiograph shows a slightly enlarged heart and mild pulmonary edema. An EKG shows ST segment elevation in anterior leads V1 - 6. Which of the following serum laboratory test findings is most likely to be present in this man?
A Urea nitrogen of 110 mg/dL
B Sodium of 115 mmol/L
C ALT of 876 U/L
D Troponin I of 32 ng/mL
E HDL cholesterol of 55 mg/dL
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(D) CORRECT. The findings suggest an early ischemic event as part of a developing myocardial infarction. The troponin I can be elevated within a few hours, similar to the CK-MB.
(A) Incorrect. If he develops cardiac failure as a consequence of his ischemic event, then he may in time develop pre-renal azotemia from diminished cardiac output.
(B) Incorrect. Hyponatremia is not typically a feature of ischemic heart disease.
(C) Incorrect. Alanine aminotransferase is an enzyme whose elevation is more specific for hepatocyte injury.
(E) Incorrect. HDL cholesterol is the 'good' cholesterol that is more protective against ischemic heart disease.
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Question 13
A 44-year-old woman dies as a consequence of a "stroke". At autopsy, she is found to have a large right basal ganglia hemorrhage. She has an enlarged 550 gm heart with predominantly left ventricular hypertrophy. Her kidneys are small, about 80 gm each, with cortical scarring, and microscopically they demonstrate small renal arterioles that have luminal narrowing from concentric intimal thickening. Which of the following is the most likely diagnosis?
A Dominant polycystic kidney disease
B Arterial changes with diabetes mellitus
C Vascular disease with hyperlipidemia
D Malignant hypertension
E Monckeberg's sclerosis
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(D) CORRECT. The small arteries of the kidney are affected by hyperplastic arteriolosclerosis. Malignant hypertension is often preceded by chronic hypertension that leads to left ventricular hypertrophy. Hypertension is a risk for CNS hemorrhage.
(A) Incorrect. Dominant polycystic kidney disease is associated with intracranial aneurysms called 'berry aneurysms' which form in adult life in a location of weakness of the arterial wall.
(B) Incorrect. Diabetes mellitus is associated with accelerated atheroclerosis that involves the larger arteries, though hyaline arteriolosclerosis can occur in the kidneys.
(C) Incorrect. Hyperlipidemia is associated with atherosclerosis, not hyperplastic arteriolosclerosis.
(E) Incorrect. This is medial calcific sclerosis and is seen in older persons in small to medium-sized muscular arteries. It produces no serious consequences.
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Question 14
A 24-year-old woman with rheumatic heart disease becomes febrile. On physical examination she has a systolic murmur. An echocardiogram shows vegetations of the aortic valve cusps. A blood culture is positive for Staphylococcus epidermidis. She receives a porcine bioprosthesis because of her desire to have children and not to take anticoagulant medication. After ten years, she must have this prosthetic valve replaced. Which of the following pathologic findings in the bioprosthesis has most likely led to the need for replacement?
A Dehiscence
B Endocarditis
C Strut failure
D Calcification
E Thrombosis
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(D) CORRECT. The bioprosthesis has the advantage of not requiring anticoagulation, but it does not wear well with time, and typically must be replaced within 5 to 10 years when its leaflets undergo progressive calcification leading to stenosis.
(A) Incorrect. Dehisence, when the suture margin comes loose, is a rare complication that manifests soon after the surgery.
(B) Incorrect. Any abnormal endocardial surface is subject to a risk for infection and development of infective endocarditis, but this is not the reason to replace the valve after 5 to 10 years.
(C) Incorrect. Bioprostheses are not subject to component failure. The mechanical prosthesis now used are also quite reliable. A certain model of valve was 'recalled' some years ago because of the tendency of one component to break, and this type of valve is no longer used.
(E) Incorrect. Patients with mechanical prostheses are given anticoagulant therapy, but persons with bioprostheses do not need this medication.
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Question 15
A 25-year-old previously healthy woman dies suddenly and unexpectedly. She had complained only of a slight headache for 3 days before her demise. At autopsy, the medical examiner finds an enlarged, dilated 410 gm heart with only minimal coronary atherosclerosis and normal cardiac valves. Microscopically, the myocardium on both the right and the left ventricles demonstrates infiltration by small lymphocytes, with focal myocyte necrosis. Which of the following infectious agents is most likely to have caused these findings?
A Coxsackie B virus
B Candida albicans
C Aspergillus fumigatus
D Streptococcus, viridans group
E Staphylococcus aureus
F Cytomegalovirus
G Streptococcus, group A
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(A) CORRECT. The most common cause for a primary myocarditis is a virus (such as Coxsackie virus). Viral myocarditis can be a cause for sudden death in a young person.
(B) Incorrect. Candida myocarditis is rare. It may occur in some immunocompromised patients.
(C) Incorrect. Fungal infections of the heart are rare. They are usually seen in immunocompromised patients.
(D) Incorrect. S. viridans is a cause for bacterial endocarditis. A myocarditis could be produced from septic emboli from vegetations, but this is not common.
(E) Incorrect. S. aureus is a cause for bacterial endocarditis. A myocarditis could be produced from septic emboli from vegetations, but this is not common.
(F) Incorrect. Cytomegalovirus is a rare cause for myocarditis, seen in immunocompromised persons.
(G) Incorrect. Group A streptococcal infections are a cause for rheumatic fever, which may produce a myocarditis with granulomatous inflammation characterized by Aschoff nodules.
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26 - venerology ( STD ) mcqs - 1 to 6

1) In AIDS, the prophylaxis for for P.Carni given when the CD4 count is

a. less than 200 / microL

b. 200 to 500/microL

c. 500 to 1000/microL

d. 1000 to 1500/microL

Answer (a) less than 200 / microL

Reference: Harrison 16^th Edition Page 1106

2) When the CD4 count is less than 200/microL in case of AIDS, the following is present

a. Cerebral Toxoplasmosis

b. Mycobacterium avium complex

c. Cytomegalovirus Infection

d. All of the above

Answer (d) All of the above

Reference: Harrison 16^th Edition Page 1106

3) Western Blot in HIV detects antibodies to products of

a. gag

b. env

c. pol

d. all of the above

Answer (d) All of the above

Reference: Harrison 16^th Edition Page 1101

4) The following are due to vasculitis in Syphilis

a. Gumma

b. Chancre

c. Both

d. None

Answer c) Both

Reference:Anathanarayanan 7^th Edition page 380

5) The most frequent cause of recurrent genital ulceration in a sexually active male is:

a. Herpes genitalis.

b. Aphthous ulcer.

c. Syphilis.

d. Chancroid.

Answer 1. Herpes genitalis.

Reference Harrison 15th Edition Chapter 132, Page 845

6) The syndromic management of urethral discharge includes treatment of:

a. Neisseria gonorrhoeae and herpes genitalis.

b. Chalamydia trachomatis and herpes genitalis.

c. Neisseria gonorrhoeae and Chlamydia trachomatis.

d. Syphilis and chancroid.

Answer 3. Neisseria gonorrhoeae and Chlamydia trachomatis.

Reference Social Hygiene Service & AIDS Unit, Department of Health, July 1998 (adapted and modified from the World Health Organisation, Regional Office for the Western Pacific)